The effect of 'community' on health

In his book, Outliers, Malcolm Gladwell tells a story of a remarkable community. Here is an abridged version:

Roseto Valfortore lies on hundred miles southeast of Rome in the Apennine foothills of the Italian province of Foggia. For centuries, the paesani of Roseto worked in the marble quarries in the surrounding hills, or cultivated the fields in the terraced valley below, walking four and five miles down the mountain in the morning and then making the long journey back up the hill at night. Life was hard.

In January of 1882, a group of eleven Rosetans – ten men and one boy – set sail for New York. They ventured west, eventually finding jobs in a slate quarry ninety miles west of the city near the town of Bangor, Pennsylvania. The following year, fifteen Rosetans left Italy for America, and several members of that group ended up in Bangor as well, joining their compatriots in the slate quarry. Those immigrants, in turn, sent word back to Roseto about the promise of the New World, and soon one group of Rosetans after another packed their bags and headed for Pennsylvania, until the initial stream of immigrants became a flood. In 1894 alone, some twelve hundred Rosetans applied for passports to America, leaving entire streets of their old village abandoned.

The Rosetans began buying land on a rock hillside connected to Bangor by a steep, rutted wagon path. They built closely clustered two-story stone houses with slate roofs on narrow streets running up and down the hillside. They called their town Roseto, which seemed only appropriate given that almost all of them had come from the same village in Italy.

In 1896, a dynamic young priest by the name of Father Pasquale de Nisco took over at the church there. De Nisco set up spiritual societies and organized festivals. He encouraged the townsfolk to clear the land and plant onions, beans, potatoes, melons, and fruit trees in the long backyards behind their houses. He gave out seeds and bulbs. The town came to life. The Rosetans began raising pigs in their backyards and growing grapes for homemade wine. Schools, a park, a convent, and a cemetery were built. Small shops and bakeries and restaurants and bars opened along the main street. More than a dozen factories sprang up making blouses for the garment trade.

Neighbouring Bangor was largely Welsh and English, and the next town over was overwhelmingly German, which meant that Roseto stayed strictly for Rosetans. Roseto, Pennsylvania, was its own tiny, self-sufficient world – all but unknown by the society around it – and it might well have remained so but for a man named Stewart Wolf.

Wolf was physician. He studied digestion and the stomach and taught in the medical school at the University of Oklahoma. He spent his summers on a farm in Pennsylvania, not far from Roseto and one of the local doctors said to him, "You know, I’ve been practicing for seventeen years. I get patients from all over, and I rarely find anyone from Roseto under the age of sixty-five with heart disease."

Wolf was taken aback. This was the 1950s, years before the advent of cholesterol-lowering drugs and aggressive measures to prevent heart disease. Heart attacks were an epidemic in the United States. They were the leading cause of death in men under the age of sixty-five. It was impossible to be a doctor and not see heart disease.

Wolf decided to investigate. He enlisted the support of some of his students and colleagues from Oklahoma. They gathered together the death certificates from residents of the town, going back as many years as they could. They analyzed physicians’ records. They took medical histories and constructed family genealogies. They set up in Roseto and took blood and did electro-cardiograms.

The results were astonishing. In Roseto, virtually no one under fifty-five had died of a heart attack or showed any signs of heart disease. For men over sixty-five, the death rate from heart disease in Roseto was roughly half that of the United States as a whole. The death rate from all causes in Roseto, in fact, was 30 to 35 percent lower than expected. They went house to house and talked to every person aged twenty-one and over. There was no suicide, no alcoholism, no drug addiction, and very little crime. They didn’t have anyone on welfare. No peptic ulcers. People were dying of old age - that’s all.

Wolf’s first thought was that the Rosetans must have held on to some dietary practices from the Old World that left them healthier than other Americans. But he quickly realized that wasn’t true. The Rosetans were cooking with lard instead of with the much healthier olive oil they had used back in Italy. Pizza in Italy was a thin crust with salt, oil, and perhaps some tomatoes, anchovies, or onions. Pizza in Pennsylvania was bread dough plus sausage, pepperoni, salami, ham, and sometimes eggs. Sweets such as biscotti and taralli used to be reserved for Christmas and Easter; in Roseto they were eaten year-round. When Wolf had dieticians analyze the typical Rosetan’s eating habits, they found that a whooping 41 percent of their calories came from fat. Nor was this a town where people got up at dawn to do yoga and run a brisk six miles. The Pennsylvanian Rosetans smoked heavily and many were struggling with obesity.

If diet and exercise didn’t explain the findings, then what about genetics? The Rosetans were a close-knit group from the same region of Italy, and Wolf’s next thought was to wonder whether they were of a particularly hardy stock that protected them from disease. So, he tracked down relatives of the Rosetans who were living in other parts of the United States to see if they shared the same remarkable good health as their cousins in Pennsylvania. They didn’t.

He then looked at the region where the Rosetans lived. Was it possible that there was something about living in the foothills of eastern Pennsylvania that was good for their health? The two closest towns to Roseto were Bangor, which was just down the hill, and Nazareth, a few miles away. These were both about the same size as Roseto, and both were populated with the same kind of hardworking European immigrants. Wolf combed through both towns’ medical records. For men over sixty-five, the death rates from heart disease in Nazareth and Bangor were three times that of Roseto. Another dead end.

What Wolf began to realize was that the secret of Roseto wasn’t diet or exercise or genes or location. It had to be Roseto itself. As they walked around the town, they figured out why. They looked at how the Rosetans visited one another, stopping to chat in Italian on the street, say, or cooking for one another in their backyards. They learned about the extended family clans that underlay the town’s social structure. They saw how many homes had three generations living under one roof, and how much respect grandparents commanded. They went to mass at Our Lady of Mount Carmel and saw the unifying and calming effect of the church. They counted twenty-two separate civic organizations in a town of just under two thousand people. They picked up on the particular egalitarian ethos of the community, which discouraged the wealthy from flaunting their success and helped the unsuccessful obscure their failures.

In transplanting the paesani culture of southern Italy to the hills of eastern Pennsylvania, the Rosetans had created a powerful, protective social structure capable of insulating them from the pressures of the modern world. “I remember going to Roseto for the first time, and you’d see three-generational family meals, all the bakeries, the people walking up and down the street, sitting on their porches talking to each other, the blouse mills where the women worked during the day, while the men worked in slate quarries. It was magical.”

When Wolf and his companions first presented their findings to the medical community, you can imagine the kind of skepticism they faced. They went to conferences where their peers were presenting long rows of data arrayed in complex charts and referring to this kind of gene or that kind of physiological process, and they themselves were talking instead about the mysterious and magical benefits of people stopping to talk to one another on the street and of having three generations under one roof. Living a long life, the conventional wisdom at the time said, depended to a a great extent on who we were – that is, our genes. It depended on the decisions we made – on what we chose to eat, and how much we chose to exercise, and how effectively we were treated by the medical system. No one was used to thinking about health in terms of community.

They had to convince the medical establishment to think about health and heart attacks in a entirely new way: they had to get them to realize that they wouldn’t be able to understand why someone was healthy if all they did was think about an individual’s personal choices or actions in isolation. They had to look beyond the individual. They had to understand the culture he or she was a part of, and who their friends and families were, and what town their families came from. They had to appreciate the idea that the values of the world we inhabit and the people we surround ourselves with have a profound effect on who we are.

So is it really Mediterrean diet or Mediterrean lifestyle that works?

We have a lot of emphasis today on 'healthy lifestyle' but I don't see 'community' or 'family' being promoted. Have we missed something?

Also how do state agencies disrupt 'community'? Do our thoughts tend toward, 'they should do something about this' rather than 'we need to do something about this'?

Malcolm Gladwell's book (which is a great read) can be bought here (other booksellers available).

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